Provider Demographics
NPI:1982129342
Name:HENDERSON SURGICAL PHYSICIAN ASSISTANT
Entity Type:Organization
Organization Name:HENDERSON SURGICAL PHYSICIAN ASSISTANT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SOFIA
Authorized Official - Middle Name:
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHYSCIAN ASSISTANT
Authorized Official - Phone:951-443-9606
Mailing Address - Street 1:12625 FREDERICK ST # I5215
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-5216
Mailing Address - Country:US
Mailing Address - Phone:951-443-9606
Mailing Address - Fax:
Practice Address - Street 1:4445 MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-4135
Practice Address - Country:US
Practice Address - Phone:951-443-9606
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-07
Last Update Date:2017-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51407363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty